Many patients are intubated in the emergency department who need brief control of their airway or behavior. In some cases, the condition requiring intubation resolves while they are still in the department. Most of the time these patients are admitted, typically to an ICU bed, for extubation. This is expensive and uses valuable resources. Is it possible to safely extubate these patients and possibly send them home?
Maryland Shock Trauma and Mount Sinai Medical Center looked at their experience in extubating selected patients in the ED. They looked at a series of 50 patients who were intubated for combativeness, sedation, or seizures. A specific protocol was followed to gauge whether or not extubation should be attempted.
None of the patients who were extubated per protocol required unplanned reintubation. One patient underwent planned reintubation when taken to the OR for an orthopedic procedure. 16% of patients were able to be discharged home from the ED.
Bottom line: A subset of patients who are intubated in the emergency department can be extubated once the inciting factor has resolved. These factors include sedation for painful procedures and combativeness. Following this protocol can reduce admission rates and reduce the use of scarce intensive care unit resources.
Click here to download a copy of the ED extubation protocol.
Related post: Trauma 20 years ago: ED intubation for head injury
Reference: Trauma patients can be safely extubated in the emergency department. J Emerg Med 40(2):235-239, 2011.
NOTE: The EMCrit blog, written by Scott Weingart, covered this topic last November. He is the first author on the paper and has created a nice podcast on the topic. You can find his blog here, and you can download the podcast here.
Coagulopathy is a frequent occurrence after severe traumatic brain injury (TBI). There are high levels of tissue factor (TF) in the brain, which can be released with severe injury. This in turn triggers a cascade which can lead to generalized coagulopathy.
The trauma group at LAC+USC looked at the time course of coagulopathy after isolated severe TBI. They identified 278 patients over a 1.5 year period and retrospectively review a number of demographic and outcome variables. Coagulopathy was defined as a platelet count < 100,000/mm3, INR > 1.4, or PTT > 36 sec.
They found the following:
- 46% with blunt trauma and 82% with penetrating injury developed a coagulopathy
- Presence of coagulopathy increased with increasing head injury severity
- Thromobocytopenia as a cause of coagulopathy was less common (17%) than clotting factor problems
- As brain injury severity increased from AIS=3 to AIS=5, median onset of coagulopathy became increasingly earlier (26 hrs, 22 hrs, 10 hrs)
- Mortality increased with earlier coagulopathy (23% after 24 hrs, 39% between 12 and 24 hrs, 56% less than 12 hrs)
- Prehospital: Coagulopathy should be suspected if the patient is bleeding profusely from multiple sites, including your IV needle sticks. This indicates severe brain injury and demands triage to a trauma center with immediate neurosurgical support.
- In-hospital: Coagulopathy that is noted in the ED portends severe injury and poor prognosis. Rapid access to CT scan and your neurosurgical consultant is critical.
Related post: Controlling fever in head injury
Reference: Time course of coagulopathy in isolated severe traumatic brain injury. Injury 41:924-928, 2010.
Intraosseous (IO) Access Techniques
Yesterday I wrote about using an intraosseous line (IO) to administer contrast for CT scanning. The authors of the paper I cited prefer using humeral head access for their IO device. I wanted to share a nice video illustrating the technique, especially for those of you who use the tibia.
The technique is simple, and better tolerated in awake, unanesthetized patients than leg access. However, I believe it’s easier to find the insertion landmarks for the tibia in obese patients.
Related post: CT contrast administration through an IO line
The standard of care in vascular access in trauma patients is the intravenous route. Unfortunately, not all patients have veins that can be quickly accessed by prehospital providers. Introduction of the intraosseous device (IO) has made vascular access in the field much more achievable. And it appears that most fluids and medications can be administered via this route. But what about iodinated contrast agents via IO for CT scanning?
Physicians at Henry Ford Hospital in Detroit have just published a case report on the use of this route for contrast administration. They treated a pedestrian struck by a car with a lack of IV access sites by IO insertion in the proximal humerus, which took about 30 seconds. They then intubated using rapid sequence induction, with drugs injected through the IO device. They performed full CT scanning using contrast injected through the site using a power injector. Images were excellent, and ultimately the patient received an internal jugular catheter using ultrasound. The IO line was then discontinued.
This paper suggests that the IO line can be used as access for injection of CT contrast if no IV sites are available. Although it is a single human case, a fair amount of studies have been done on animals (goats?). The animal studies show that power injection works adequately with excellent flow rates.
The authors prefer using an IO placement site in the proximal humerus. This does seem to cause a bit more pain, and takes a little practice. A small xylocaine flush can be administered to reduce injection discomfort in awake patients. Additionally, the arm cannot be raised over the head for the torso portion of the scan.
Bottom line: CT contrast can be injected into an intraosseous line (IO) with excellent imaging results. Insert the IO in a site that you are comfortable with. I do not recommend power injection at this time. Although the marrow cavity can support it, the connecting tubing may not. Have your radiologist hand-inject and time the scan accordingly.
Note: long term effects of iodinated contrast in the bone marrow are not known. For this reason, and because of smaller marrow cavities, this technique is not suitable for pediatric patients.
Related post: Air embolism from an intraosseous line
Reference: Intraosseous injection of iodinated computed tomography contrast agent in an adult blunt trauma patient. Annals Emerg Med 57(4):382-386, 2011.
Yesterday, I wrote about using ultrasound in place of CT for initial diagnosis of blunt abdominal injury in children. Although it looks good for identification of solid organ injury and free fluid, it may miss injury to the intestine. Is that bad?
Lets look at a recent study that examined the consequences of delayed laparotomy for blunt intestinal injury. The American Pediatric Surgical Association conducted an 18-center study of the management of intestinal injuries in children less than 16 years of age. They were stratified by time to treatment. There were 214 patients with complete data records for review.
The majority of the patients were involved in a motor vehicle crash or a bicycle accident. Demographics were similar in all time to treatment groups. Half were resuscitated at a referring hospital and then transferred to a pediatric trauma center, on average after 6 hours.
- The only deaths occurred in the 0-6hr and 6-12hr groups. The average Injury Severity Score of the children who died was significantly higher than survivors.
- Children operated on in the 0-6hr group had significantly higher ISS as well.
- There was no difference in early or late complications across all groups.
- Time to beginning oral intake and time in hospital were the same in all groups.
The authors concluded that observation and serial exam rather than urgent exploration or repeated CT scans is appropriate.
Bottom line: If you combine this study with the ultrasound study I reviewed yesterday, it seems appropriate to modify the usual (read: adult) way of evaluating blunt trauma to the abdomen. In place of automatically getting a CT scan of the abdomen in children, obtain a complete abdominal ultrasound to detect solid organ injury or free fluid. This will determine the degree of monitoring needed (e.g. ICU for higher grade liver or spleen injuries). Follow this with serial abdominal exam. If the child becomes symptomatic, it’s probably time to proceed to the OR. Note: I generally do not make children npo during the observation phase. They need to eat, and if they don’t want to, that tells you something.
Related post: Sonography in pediatric abdominal trauma
Reference: Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric patient. J Pediatric Surg 45(1):161-166, 2010.